Therapeutic / Relaxation Massage Intake Form

Please select which location you are submitting this form to:

First Name: *
Last Name: *

Phone (Day): *

Phone (Evening): *

Address: *

City:
Province:
Postal Code:

Your email: *

Date of Birth: *

Occupation: *

How Did You Hear About Us? *

Google Search
Facebook
YouTube
Website
Walk In




Emergency Contact *

Name:
Phone:

Preferred massage times *

What is your preferred massage time?

Open hours:
Monday to Friday: 7:00am - 7:30pm
Saturday: 8:00am - 2:00pm



The following information will be used to help plan safe and effective massage sessions.
Please answer the questions to the best of your knowledge.

1. Do you have any difficulty lying on your front, back or side?  Yes No

2. Do you have any allergies to oils, lotions or ointments?  Yes No

3. Do you have sensitive skin?  Yes No

4. Do you sit for long hours at a workstation, computer or driving?  Yes No

5. Do you perform any repetitive movement in your work, sports or hobby?  Yes No

6. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?  Yes No

7. How long since your last massage? *


Medical History

In order to plan a massage session that is safe and effective, I need some general information about your medical history.

8. Are you currently taking any medication? *  Yes No

 Contagious skin condition
 Open sores or wound
 Recent accident or injury
 Recent surgery
 Sprains/strains
 Swollen glands
 Heart condition
 Circulatory disorder
 Atherosclerosis
 Osteoporosis
 Headaches/migraines
 Diabetes
 Back/neck problems
 TMJ
Pregnant? *  Yes No

If yes, how many months:

 Easy bruising
 Recent fracture
 Artificial joint
 Current fever
 Allergies/sensitivity
 High or low blood pressure
 Varicose veins
 Epilepsy
 Cancer
 Tennis elbow
 Fibromyalgia
 Carpal tunnel syndrome
 Joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis
 Deep vein thrombosis/blood clots

History of accident or surgery: *



Informed written consent must be provided by parent or legal guardian for any client under the age of 17.

I, understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. I further understand that massage should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician, physical therapist, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so.

A cancellation fee of $90.00 will be charged in the event of a "No Show" appointment or less than 24 hours notice.



 I agree to the statement(s) above *
Date